Common ENT emergencies

1. COMMON ENT COMMON ENT
EMERGENCIESEMERGENCIES
Thongchai LuxameechanpornThongchai Luxameechanporn
ENT departmentENT department
Ramathibodi hospitalRamathibodi hospital

2. Common ENT emergenciesCommon ENT emergencies
Foreign bodiesForeign bodies
TraumaTrauma
Complications of ENT infectionsComplications of ENT infections

4. Foreign bodies Foreign bodies
InsectsInsects
Cotton, paper, organic Cotton, paper, organic
materialmaterial
Small batteriesSmall batteries
Discomfort & agitationDiscomfort & agitation
Secondary complications: Secondary complications:
infection & mucosal infection & mucosal
erosionerosion

5. Foreign bodiesForeign bodies
Kill any live insectsKill any live insects
Remove foreign body Remove foreign body
with micro alligator with micro alligator
forcepsforceps
Irrigation ( do not use if Irrigation ( do not use if
organic FB )organic FB )

6. Auricular HematomaAuricular Hematoma
Usually from traumaUsually from trauma
Fluctuant bluish swelling Fluctuant bluish swelling
of auricleof auricle
DrainageDrainage
- Needle aspiration- Needle aspiration
- I & D- I & D
Apply compression Apply compression
dressingdressing

7. Traumatic TM PerforationTraumatic TM Perforation
Compression, Compression,
instrumentation & instrumentation &
blast injuriesblast injuries
Hearing testHearing test
Close observation if Close observation if
perforation is smallperforation is small
Paper patchPaper patch
SurgerySurgery

8. Temporal bone fractureTemporal bone fracture
Blunt head injuryBlunt head injury
Longitudinal Fx Longitudinal Fx → → facial facial
n. paralysis, CHL n. paralysis, CHL
(ossicular chain (ossicular chain
disruption)disruption)
Transverse Fx Transverse Fx → → SNHL, SNHL,
dysequilibrium, CN dysequilibrium, CN
VII palsyVII palsy

9. Temporal bone fracture Temporal bone fracture
Battle’s sign (bluish Battle’s sign (bluish
discoloration of discoloration of
postauricular region), postauricular region),
raccoon eyes, raccoon eyes,
hemotympanum, hearing hemotympanum, hearing
loss, dizziness, CSF loss, dizziness, CSF
otorrhea, CN VII palsyotorrhea, CN VII palsy
CT temporal boneCT temporal bone

10. Acoustic traumaAcoustic trauma
Sudden exposure (impact or blast) to noiseSudden exposure (impact or blast) to noise
SHNL, tinnitusSHNL, tinnitus
Avoidance/ ear protectionAvoidance/ ear protection
Corticosteroids, carbogen, vasodilators, Corticosteroids, carbogen, vasodilators,
diuretics, anticoagulants, plasma expandersdiuretics, anticoagulants, plasma expanders

11. Otitic BarotraumaOtitic Barotrauma
Inability to ventilate Inability to ventilate
middle ear middle ear → → abnormal abnormal
dysfunction of ETdysfunction of ET
Occur in rising ambient Occur in rising ambient
pressure (descent in flight pressure (descent in flight
/ scuba diving)/ scuba diving)
Can produce Can produce
hemotympanumhemotympanum

12. BarotraumaBarotrauma
Repeated Valsalva Repeated Valsalva
maneuvermaneuver
Topical nasal Topical nasal
decongestantsdecongestants
Myringotomy & PE tube Myringotomy & PE tube
insertion may be neededinsertion may be needed

13. Sudden Hearing LossSudden Hearing Loss
SNHL ≥ 30 dB over 3 SNHL ≥ 30 dB over 3
contiguous frequencies contiguous frequencies
within 3 days or lesswithin 3 days or less
Etiology : Viral & Etiology : Viral &
Infectious, Vascular, Infectious, Vascular,
Trauma, Autoimmune, Trauma, Autoimmune,
Neurologic Neurologic

14. Complications of ME infectionsComplications of ME infections
ExtracranialExtracranial

15. Acute MastoiditisAcute Mastoiditis
preceded by AOMpreceded by AOM
young childrenyoung children
severe pain, fever, edemasevere pain, fever, edema
over mastoid areaover mastoid area
intravenous ATBintravenous ATB
Myringotomy ± PE tubeMyringotomy ± PE tube

16. Subperiosteal AbscessSubperiosteal Abscess
pinna pushed pinna pushed
down & outward down & outward
intravenous ATBintravenous ATB
I&DI&D
mastoidectomy mastoidectomy

17. Complications of ME infectionsComplications of ME infections
IntracranialIntracranial

19. Foreign bodies: SymptomsForeign bodies: Symptoms
Purulent unilateral nasal Purulent unilateral nasal
dischargedischarge
Usually lodge on the floor Usually lodge on the floor
of anterior or middle of anterior or middle
thirdthird

20. Foreign bodies: ManagementForeign bodies: Management
Good visualization: Good visualization:
headlamp & nasal speculumheadlamp & nasal speculum
Alligator forceps should be Alligator forceps should be
used to remove cloth, cotton, used to remove cloth, cotton,
or paper or paper
Other hard FB are more Other hard FB are more
easily grasped using bayonet easily grasped using bayonet
forceps or Kelly clamps, or forceps or Kelly clamps, or
they may be rolled out by they may be rolled out by
getting behind it using an ear getting behind it using an ear
curette, single skin hook, or curette, single skin hook, or
right angle ear hookright angle ear hook

21. Nasal FractureNasal Fracture
Hx of fall or force Hx of fall or force
directed to midfacedirected to midface
Deformity of noseDeformity of nose
Swelling, ecchymosis, Swelling, ecchymosis,
epistaxisepistaxis
Close or open reductionClose or open reduction

22. Septal hematoma/abscessSeptal hematoma/abscess
Trauma, surgeryTrauma, surgery
Soft, fluctuant swelling of Soft, fluctuant swelling of
septumseptum
Needle Needle aaspiration spiration
oror I&D I&D
Bilateral nasal packing for Bilateral nasal packing for
several daysseveral days
Prophylactic antibioticsProphylactic antibiotics

23. Septal hematoma/abscessSeptal hematoma/abscess

24. EpistaxisEpistaxis
LocalLocal
Trauma /Nose picking or Trauma /Nose picking or
blowing / surgeryblowing / surgery
Dry air / Irritants Dry air / Irritants
Topical medications Topical medications
(steroids)(steroids)
Foreign body Foreign body
Tumor / polypTumor / polyp
SystemicSystemic
Blood diseasesBlood diseases
Hereditary hemorrhagic Hereditary hemorrhagic
telangiectasiatelangiectasia
Drugs (anticoagulants)Drugs (anticoagulants)
HypertensionHypertension

25. Epistaxis Epistaxis

26. EpistaxisEpistaxis
Initial first-aidInitial first-aid
Assessment of blood lossAssessment of blood loss
Evaluation of cause Evaluation of cause
Procedure to stop Procedure to stop
bleedingbleeding
Most common Most common → →
Kiesselbach’s Plexus Kiesselbach’s Plexus
Squeeze nose 5-20 minsSqueeze nose 5-20 mins
Insert cotton pledget Insert cotton pledget
(with decongestant)(with decongestant)
Cautery with silver nitrate Cautery with silver nitrate

27. Pope, L E R et al. Postgrad Med J 2005;81:309-314
Figure 1 Epistaxis management protocol.

28. Epistaxis Epistaxis

29. Anterior nasal packingAnterior nasal packing
Local anesthetic & Local anesthetic &
decongestant decongestant
Nasal packingNasal packing
- - Vasaline guazeVasaline guaze
- Absorbable gelfoam- Absorbable gelfoam
- Oxidized cellulose- Oxidized cellulose
(Surgicel) (Surgicel)
- Nasal tampon- Nasal tampon

30. Anterior nasal packingAnterior nasal packing

31. Anterior nasal packingAnterior nasal packing
Nasal packingNasal packing
- - Vasaline guazeVasaline guaze
- - Absorbable gelfoamAbsorbable gelfoam
- Oxidized cellulose- Oxidized cellulose
(Surgicel)(Surgicel)
- Nasal tampon- Nasal tampon

32. Anterior nasal packingAnterior nasal packing
Nasal packingNasal packing
- - Vasaline guazeVasaline guaze
- - Absorbable gelfoamAbsorbable gelfoam
- Oxidized cellulose- Oxidized cellulose
(Surgicel) (Surgicel)
- Nasal tampon- Nasal tampon

33. Anterior nasal packingAnterior nasal packing
Nasal packingNasal packing
- - Vasaline guazeVasaline guaze
- Absorbable gelfoam- Absorbable gelfoam
- Oxidized cellulose- Oxidized cellulose
(Surgicel) (Surgicel)
- - Nasal tamponNasal tampon

34. Copyright ©2005 BMJ Publishing Group Ltd.
Pope, L E R et al. Postgrad Med J 2005;81:309-314
Figure 2 Correct insertion of a nasal tampon (note that the direction is along the floor of the nasal
cavity).

35. Posterior nasal packingPosterior nasal packing
Topical anesthetic & Topical anesthetic &
decongestantdecongestant
Posterior nasal Posterior nasal
packingpacking
Double balloon deviceDouble balloon device
Foley catheterFoley catheter

36. Posterior nasal packingPosterior nasal packing
Topical anesthetic & Topical anesthetic &
decongestantdecongestant
Posterior nasal packing Posterior nasal packing
Double balloon deviceDouble balloon device
Foley catheterFoley catheter

37. Posterior nasal packingPosterior nasal packing
Topical anesthetic & Topical anesthetic &
decongestantdecongestant
Posterior nasal packing Posterior nasal packing
Double balloon deviceDouble balloon device
Foley catheterFoley catheter

38. Complications of sinusitisComplications of sinusitis
Orbital complicationsOrbital complications
Intracranial complicationsIntracranial complications

39. Classification of orbital inflammationClassification of orbital inflammation
StageStage
II

IIII
IIIIII
IVIV
VV
InflammationInflammation
Inflammatory edemaInflammatory edema
(periorbital cellulitis)(periorbital cellulitis)
Orbital cellulitisOrbital cellulitis
Subperiosteal abscessSubperiosteal abscess
Orbital abscessOrbital abscess
Cavernous sinus thrombosisCavernous sinus thrombosis

40. Complications of sinusitisComplications of sinusitis
Periorbital cellulitis: Periorbital cellulitis:
periorbital erythema, periorbital erythema,
edema, pain & feveredema, pain & fever
Purulent nasal dischargePurulent nasal discharge
S.pneumoniae, S.aureus, S.pneumoniae, S.aureus,
coagulase-negative coagulase-negative
staphylococcistaphylococci
Broad-speculum Broad-speculum
antibioticsantibiotics

41. Complications of sinusitisComplications of sinusitis
Orbital complications Orbital complications
(stages II-V)(stages II-V)
Periorbital swelling & Periorbital swelling &
pain, feverpain, fever
Proptosis, chemosis, Proptosis, chemosis,
restriction of ocular restriction of ocular
movement & visual movement & visual
disturbancedisturbance

42. Complications of sinusitisComplications of sinusitis
CT scan CT scan → → subperiosteal subperiosteal
& orbital abscess& orbital abscess
Admission & IV broad- Admission & IV broad-
spectrum antibioticsspectrum antibiotics
Surgery (drainage) ifSurgery (drainage) if
- failed medication - failed medication
- develop abscess- develop abscess
- visual drop- visual drop

43. Complications of sinusitisComplications of sinusitis
Intracranial complicationsIntracranial complications
Cavernous sinus thrombosis, meningitis, Cavernous sinus thrombosis, meningitis,
extradural abscess, intracranial abscess & extradural abscess, intracranial abscess &
subdural empyemasubdural empyema
Purulent rhinorrhea, fever, frontal/retro-orbital Purulent rhinorrhea, fever, frontal/retro-orbital
headacheheadache
Personality change/lethargy, seizures, N/V, Personality change/lethargy, seizures, N/V,
focal neurological deficits focal neurological deficits

44. Complications of sinusitisComplications of sinusitis
Intracranial complicationsIntracranial complications
Diagnosis Diagnosis → → MRI scan with gadoliniumMRI scan with gadolinium
Admission, IV broad-spectrum antibiotics & Admission, IV broad-spectrum antibiotics &
surgical drainagesurgical drainage

46. Swallowed foreign bodySwallowed foreign body
Peanuts, coins, batteries, Peanuts, coins, batteries,
fish bone, meat & bone fish bone, meat & bone
pieces, denturespieces, dentures
Location of pain indicates Location of pain indicates
FB locationFB location

47. Swallowed foreign bodySwallowed foreign body
Fish bones tend to lodge Fish bones tend to lodge
in oropharynx, produced in oropharynx, produced
ipsilateral symptomsipsilateral symptoms
Esophagus FB localize in Esophagus FB localize in
midline: dramatic acute midline: dramatic acute
dysphagia dysphagia

48. Swallowed Foreign bodiesSwallowed Foreign bodies
Most FB in oropharynx Most FB in oropharynx
can be identifiedcan be identified
Esophageal FB: pooling Esophageal FB: pooling
of saliva in piriformof saliva in piriform
X-rays may be helpful in X-rays may be helpful in
radio-paque objectsradio-paque objects

49. Swallowed Foreign bodiesSwallowed Foreign bodies
Visualized FB can be Visualized FB can be
removed with angled removed with angled
forcepsforceps
Sharp FB should be Sharp FB should be
removed at the earliest removed at the earliest
opportunity due to risk of opportunity due to risk of
perforationperforation

50. Swallowed Foreign bodiesSwallowed Foreign bodies
Coins Coins → → removed if in removed if in
cervical or mid esophagus cervical or mid esophagus
→ → removed within 12 hrs removed within 12 hrs
if in distal esophagusif in distal esophagus
Batteries Batteries → → removed removed
emergency emergency

51. Swallowed Foreign bodiesSwallowed Foreign bodies
Airway compromiseAirway compromise
- Heimlich maneuver- Heimlich maneuver
- Emergency- Emergency
cricothyrotomy/ cricothyrotomy/
tracheostomytracheostomy
Endoscopy with removal Endoscopy with removal
in ORin OR

52. Inhaled Foreign bodiesInhaled Foreign bodies
Sudden onset of Sudden onset of
coughing, wheezing or coughing, wheezing or
stridor in previously stridor in previously
healthy childhealthy child
Unilateral wheezing, poor Unilateral wheezing, poor
chest movement & chest movement &
reduced breath soundreduced breath sound
CXR: hyperinflate, CXR: hyperinflate,
infection, collapseinfection, collapse

53. Inhaled Foreign bodiesInhaled Foreign bodies
Heimlich manuverHeimlich manuver
Secure airway Secure airway
Endoscopic removal Endoscopic removal
under general anesthesiaunder general anesthesia

54. Airway ObstructionAirway Obstruction
Neonatal Neonatal :: Congenital tumors, cysts, webs Congenital tumors, cysts, webs

: Laryngomalacia: Laryngomalacia
: Subglottic stenosis: Subglottic stenosis
Children : LaryngotracheobronchitisChildren : Laryngotracheobronchitis
: Supraglottitis (epiglottitis): Supraglottitis (epiglottitis)
: Foreign body: Foreign body
: Retropharyngeal abscess: Retropharyngeal abscess
: Respiratory papilloma: Respiratory papilloma
Adults : Laryngeal cancer Adults : Laryngeal cancer
: Laryngeal trauma: Laryngeal trauma
: Epiglottis & deep neck infection: Epiglottis & deep neck infection

55. Deep neck infectionsDeep neck infections

56. Peritonsillar abscessPeritonsillar abscess
Pus forms between Pus forms between
tonsils capsule & superior tonsils capsule & superior
constrictorconstrictor
Group A StreptococcusGroup A Streptococcus

57. Peritonsillar abscessPeritonsillar abscess
Severe, unilateral sore Severe, unilateral sore
throatthroat
feverfever
Hot potato voiceHot potato voice
Uvula deviates to Uvula deviates to
opposite sideopposite side
Swollen tonsilsSwollen tonsils

58. Peritonsillar abscessPeritonsillar abscess
CBC, throat C/SCBC, throat C/S
Antibiotics Antibiotics
- Oral - Oral
- Parenteral - Parenteral
needle aspiration or I&Dneedle aspiration or I&D

59. Ludwig’s AnginaLudwig’s Angina
Rapid swelling cellulitis of Rapid swelling cellulitis of
sublingual & submaxillary sublingual & submaxillary
spacesspaces
Dental infection, floor of Dental infection, floor of
mouth, salivary glandmouth, salivary gland
Fever, edema & erythema Fever, edema & erythema
of neck under chin & of neck under chin &
floor of mouthfloor of mouth

60. Ludwig’s AnginaLudwig’s Angina
Open mouth, Open mouth,
Tongue Tongue → → upward & upward &
backwardbackward →→ airway airway
obstructionobstruction
Streptococci, Bacteroides, Streptococci, Bacteroides,
S.aeruesS.aerues
TracheostomyTracheostomy
IV antibioticIV antibiotic
I&D, tooth extractionI&D, tooth extraction

61. EpiglottitisEpiglottitis
Age 3-7 yrs oldAge 3-7 yrs old
H. influenzae H. influenzae type B, type B,
Group A Group A Streptococcus Streptococcus
severe sore throat & fever, severe sore throat & fever,
dysphagia, drooling dysphagia, drooling
StridorStridor
Breathing with raised chin Breathing with raised chin
& open mouth& open mouth

62. EpiglottitisEpiglottitis
CBC: leukocytosisCBC: leukocytosis
Film lateral neck Film lateral neck → →
thumb shaped epiglottisthumb shaped epiglottis
Avoid tongue depressorAvoid tongue depressor
Controlled intubationControlled intubation
Intravenous ATBIntravenous ATB

63. Retropharyngeal AbscessRetropharyngeal Abscess
Infants & childrenInfants & children
Secondary to Secondary to
oropharyngeal infectionoropharyngeal infection
Severe dysphagia & Severe dysphagia &
respiratory distressrespiratory distress
airway observationairway observation
IV antibioticIV antibiotic
Surgical drainageSurgical drainage
( prevent pus aspiration)( prevent pus aspiration)

64. TracheostomyTracheostomy
Emergency tracheostomyEmergency tracheostomy
in the case of upper airways in the case of upper airways
obstructionobstruction
1. Tumor in the larynx1. Tumor in the larynx
2. Trauma of the larynx2. Trauma of the larynx
3. Bilateral vocal cord 3. Bilateral vocal cord
paralysisparalysis
4. F.B. in the larynx after 4. F.B. in the larynx after
failure of Heimlich’s failure of Heimlich’s
manuver manuver